NHS Forth Valley

Induction of Labour

Patient Information Leaflet The date of your induction is

______This will take place in Forth Valley Royal Hospital. You have been given a date to come into hospital for induction of your labour. This leaflet aims to answer some of the questions you may have about what this involves. If you have any other questions please contact a midwife in Triage 01324 567098.

What is induction of labour?

Labour is a natural process that usually starts on its own between 37 and 42 weeks of pregnancy. Induction of labour is the process of starting labour artificially.

Why you might be offered induction?

The most common reason for induction of labour is when your baby is overdue. Induction is usually recommended by 42 weeks gestation as after this time the placenta may become less efficient and make complications more likely in some babies (NICE 2008). If your pregnancy has been normal we offer induction between 10 and 14 days after your due date. Induction is sometimes offered for other reasons such as you have raised blood pressure or if it is thought your baby is small. If it is felt that you or your baby’s health is likely to benefit, the Doctor may recommend induction of labour earlier. The Doctor will explain how having your labour induced will help you and your baby.

If you are offered induction

When induction of labour is being considered your team Midwife or Doctor will discuss your options with you before any decision is reached. This should include explaining the procedure, the care that will be involved, and 2 any risks to you and your baby. If you choose not to go ahead with induction, your Midwife or Doctor will discuss your care options with you. If you decide to have your labour induced your team Midwife will arrange a date with you for admission to antenatal/postnatal ward. This date will depend on availability, as you will realise, only a certain amount of inductions can be safely carried out each day. On occasions, if the ward and or the Unit is very busy, your induction may need to be delayed – if this happens you will be given a full explanation as to the reason and you may be asked to return later that day or the following day.

Where will I be induced?

You will be given an appointment to go to Forth Valley Royal Hospital. You should have your breakfast before you come to the ward and we also advise you to eat and drink normally whilst on the ward. Your partner is welcome to stay with you during the day but will be asked to go home at 9pm if you are not in labour. If labour does start during the night your partner can be called to be with you in the labour ward.

Why might my induction be postponed or delayed?

Midwives and doctors understand that, when your IOL is either postponed in the first place or delayed whilst you are in hospital, that you will be very upset. However the safety of you and your baby is paramount and distressing though the event may be a delay may be the safest option. Your induction of labour will be postponed if: l The workload on Delivery Suite means there is no midwife available to care for you at the time l The midwives and doctors have to prioritise mothers and babies for induction of labour, and another mother may have a greater need at the time than you. 3 How is labour induced?

Listed below are the ways your labour may be induced. The method chosen depends upon your individual circumstances and how “favourable” your cervix is. A favourable or ripe cervix is when it has become softer and thinner; an unfavourable or unripe cervix is where it is firm, closed and long. You may be offered one or all of these methods to induce your labour: l Pessary or gel l Breaking the bag of waters around the baby (artificial rupture of membranes) l Oxytocin drip A Midwife or a Doctor will perform an internal vaginal examination to assess the cervix; this helps us decide which method of induction is best for you. Priming the cervix l Pessary or gel prostaglandins Prostaglandins are drugs that act like the natural hormones that “triggers off” labour and are used to “prime” the cervix. This process makes the cervix softer and shorter, preparing it for induction of labour. Prostaglandins are inserted into the vagina as a gel or a pessary.

What are the risks associated with prostaglandins?

Prostaglandins are very safe. Serious side effects from the drugs used are very rare. Some women develop “prostin” contractions, which can be painful, and may cause diarrhoea. Occasionally some women develop a prolonged contraction which can affect the baby’s heart beat. For this reason we will monitor your baby’s heart beat continuously for about 20 minutes before, and 60 minutes after, you have been given the prostaglandin. A small number of women don’t respond to the prostaglandins and we say the induction has “failed”. In these rare cases we may need to perform a caesarean section to deliver the baby. 4 Prostaglandin Pessary

A slow releasing prostaglandin pessary which stays in place for 24 hours is given when the cervix is found to be less favourable.

Prostaglandin Gel

Prostaglandin gel is given when the cervix is more favourable. Sometimes just one dose is required, but many women require more with a second dose given after 6 hours. Some women will require further gel the next day. If your labour has not started after the first day with either the gel or pessary a Doctor or a Midwife will examine you internally the next morning. You may need more prostaglandins or it may be possible to break your waters.

How long will it take my labour to start after “priming”?

Most women do not go into labour with prostaglandins and labour will be induced as described in the next section once the cervix is favourable. A few women will not respond to the prostaglandins and also there will be some women who over respond and have a very rapid labour without any further treatment. If your labour has not started by the third day a Doctor will come and review you and your baby and discuss your care; you may be given the choice to have a day at home to rest. Occasionally, your induction may last for up to 4-5 days. A Doctor will review you and your baby’s progress daily.

What might I expect to feel?

After the gel/pessary is given you may experience some crampy like ‘period’ pains, backache and sometimes you may feel a burning sensation in your vagina. You may occasionally feel discomfort at the top of your thighs – this is known as effacement pain (cervix shortening). Please discuss any concerns or symptoms with your midwife. The midwife will check on you and your baby’s wellbeing regularly. 5 What can I do to help the discomfort? l Some women find that walking around eases their discomfort; this can also help to get your labour established. l Do you remember the relaxation and breathing methods you practised in your parentcraft classes? Do not worry if you do not know or remember, the Midwife will tell you about them. l We can give you a ‘hot pack’ to help relieve any backache you may have; your partner could also massage your back for you. l If you have a TENS machine you could use it to help relieve any discomfort. l You could also try a bath or shower – ask the Midwife. l We can also give you pain relieving tablets if you wish, for example Paracetamol.

Induction of labour l Breaking the waters to induce labour This is performed by a Midwife or a Doctor during an internal examination. This is usually no more uncomfortable than any other internal examination. A small instrument called an amnihook is used to nick the membranes in front of the baby's head - it looks very much like a crochet hook. This is also called artificial rupture of the membranes (ARM). As this procedure requires your cervix to have started to dilate, it is usually only performed in women who have given birth to a baby before or as in a second step in women who have already had prostaglandin. If your contractions do not start spontaneously, we will recommend you have a drug called syntocinon via a drip (see below). Sometimes we will recommend that the syntocinon drip be started as soon as the waters have been broken.

6 l Syntocinon (oxytocin) drip to induce labour Oxytocin is a drug that is given through a drip into your blood stream. This makes your uterus contract. The rate of the drip is increased until you are having regular strong contractions. It continues until after your baby is born. Whilst having the drip your baby’s heart rate will be continuously monitored. Your ability to walk around will be limited by the drip and monitor although you may choose to stand up, sit in a chair or on a birthing ball. Your waters should usually be broken before oxytocin can be used.

When will I go to the labour ward? l When your labour establishes (regular, rhythmic painful contractions accompanied by shortening and dilatation of your cervix). l If your ‘waters’ can be broken, or if your ‘waters’ break naturally during your induction. l If we have any concerns regarding you or your baby Following induction your labour should continue as usual.

If induction doesn’t work

Your Midwife and Doctor will discuss this with you, and check on you and your baby. Depending on your wishes and circumstances, you will usually be offered a caesarean section if labour does not progress after ARM and a syntocinon drip. We hope this leaflet will answer some of the questions you may have, but do not hesitate to speak to a Midwife or a Doctor.

Reference: National Institute for Health and Care Excellence (NICE) 2008 Induction of Labour Royal College of Obstetricians and Gynaecologists Press.

7 If you can’t go let us know! Every month around 2,000 people across Forth Valley fail to turn up for hospital appointments. This costs the NHS millions of pounds each year and increases waiting times. So if you are unable to attend or no longer require your hospital appointment please let us know so we can offer it to someone else.

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